The Family Included team regards this research as among the most valuable that has come forward in the past year and strongly recommends anyone considering the practical implementation of family inclusive care to read the full article and make contact with the team in Tanzania. (Contact details below.)
The Tanzanian Ministry of Health, in line with WHO recommendations, emphasises the particular importance of male involvement during ANC, but in common with everywhere else in the developing world where such aspirations exist, there is a gap between aspiration and reality.
The African Woman Foundation, through its Woman Centred Care Project, set about finding out why this is the case in a rural district of Tanzania, Magu. The research consisted of observations, focus groups and interviews. A total of 9 focus groups were held of 2-3 hours each including 6-12 participants with a total of 40 men and 26 women. Interviews were held with 26 men of whom some had accompanied their wives, some had not and some had wives who had not attended clinics either. In addition, a questionnaire sought information and views from 156 women regarding their partners’ involvement in their pregnancy.
In common with other studies, the attitudes towards male involvement were positive. Men were positive, women also. Health care workers and traditional birth attendants also generally supported the approach of involving men. So why does the practice remain so rare?
The research revealed a number of barriers:
- In Tanzania, attendance at antenatal clinics is used as a method to hook men into HIV testing. Whilst Government policy declares the benefits of men attending antenatal clinics, and invitations to antenatal clinics may state the importance of information and education for men, in reality the primary reason, known to everyone, is HIV testing and this is the only outcome by which antenatal clinics are measured. So the failure of men to attend antenatal clinics is, in reality, a failure to promote an HIV testing programme.
- Social and cultural norms are often presented as a barrier, though these do not constrain behaviour in all families. They include the shame men may feel if they do domestic work and a feeling that pregnancy is a woman’s issue only (a belief that both women and men may hold).
- Lack of knowledge about why it is important for men to be engaged.
- Perceived low accessibility of antenatal clinics to men and stories of their unfriendliness towards men (as well as towards the women themselves). For example, one question asked by a father in the study: what is the point of going if you just have to wait outside?
- Distance to travel and cost for men with high earning responsibilities. One man during a ‘men only’ focus group discussion, however, contradicted this, saying that better time management can solve such problems, an opinion that met with general agreement.
The researchers conclude with a number of recommendations for solutions.
The need for direct communication with men
Requiring pregnant women to be the conduits of information to husbands is unsatisfactory. Health care workers easily forget to tell the women and women can choose not to tell their husbands either because of their own gender beliefs or because of the fear of appearing “demanding” about the need to change behaviour, for example, working less and eating more expensively.
The importance of direct communication was made by participants of focus groups thus:
“Men will hear the advice together, making them able to collaborate in pregnancy’, ‘husbands will be less ignorant of advice given by HCWs, knowing reduction of activities by their wives is not laziness’, ‘HIV testing involves both of them’.”
Merely attending an antenatal clinic without gaining a better understanding is of little value.
Antenatal facilities need to take responsibility for being accessible and male friendly
Training of health care workers is regarded as important, providing them with additional tools “as HCWs have opportunities to motivate and educate couples attending ANC and make husbands feel more welcome through creating a more male-friendly environment”.
Also “appropriate policy, space and staffing inviting men to attend clinics and births would, according to some studies, increase the quality of care. Possibilities for longer clinic hours, separate counselling rooms for couples and training of health care workers could be also considered, depending on the local needs.”
Compelling men to attend is not the answer
Despite the practice of enforced male attendance during antenatal care clinics being implemented in one village in the study area, Isolo, and a consequent increase in the participation of men, the researchers do not advocate this approach, because the penalties all fall on the pregnant women, for example, shaming and denial of care.
Besides, this approach does not lead to a greater understanding of the issues by men. It creates barriers for unmarried women (already a vulnerable group), and it limits women’s choices and their autonomy, thereby simply reinforcing the very gender inequalities that male involvement aims to challenge.
The key is information and education
The researchers report on how men in the study view the importance of information:
Most men were positive about increasing their knowledge and many were even explicitly asking for education concerning pregnancy-related issues. Education could make them ‘realise the importance of supporting their pregnant wives’, ‘become less ignorant’, ‘proactive instead of only reactive’, ‘finish with traditional gender roles’, and ‘motivate them to attend ANC together’ (respondents during interviews and FGD’s).
The need for education and information also applies to health care workers, as referred to above.
Community engagement is important
The commitment and collaboration of the entire community is important, with increased awareness on the part of both women and men.
Vermeulen E, Solnes Miltenburg A, Barras J, Maselle N, van Elteren M & van Roosmalen J (2016), Opportunities for male involvement during pregnancy in Magu district, rural Tanzania, BMC Pregnancy and Childbirth 16
Contact person: Andrea Solnes Miltenburg, African Woman Foundation and Department of Community Medicine, Institute of Health and Society, Medical Faculty, University of Oslo, Norway.
Photo: CIFOR. Creative Commons.